A nurse is administering the Haemophilus influenzae type B vaccine (Hib) to a 6-month-old infant. Which of the following actions should the nurse take?
Administer the vaccine in the vastus lateralis muscle using a 25-mm (1-in) needle
Administer the vaccine subcutaneously in the abdomen using a 16-mm in needle
Administer the vaccine subcutaneously in the upper arm using a 13-mm (-n) needle.
Administer the vaccine in the dorsogluteal muscle using a 51 mm (2-in) needle
The Correct Answer is A
A. Administer the vaccine in the vastus lateralis muscle using a 25-mm (1-in) needle: For infants, the vastus lateralis muscle in the thigh is the preferred site for intramuscular (IM) vaccinations, including the Hib vaccine. A 25-mm (1-in) needle is an appropriate length for this muscle in a 6-month-old infant.
B. Administer the vaccine subcutaneously in the abdomen using a 16-mm (5/8-in) needle: The Hib vaccine is not administered subcutaneously. It is an intramuscular injection, and the abdomen is not the recommended site for this vaccine.
C. Administer the vaccine subcutaneously in the upper arm using a 13-mm (1/2-in) needle: The Hib vaccine is administered intramuscularly, not subcutaneously. The upper arm is used for intramuscular injections in older children. A 13-mm needle is too short for an intramuscular injection in the vastus lateralis.
D. Administer the vaccine in the dorsogluteal muscle using a 51-mm (2-in) needle: The dorsogluteal muscle is not recommended for infants due to the risk of damaging the sciatic nerve. A 2-inch needle is too long for this area in an infant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Latex gloves: Latex gloves should be avoided, especially in newborns, due to the risk of allergic reactions. Non-latex gloves are the preferred option for any care involving newborns.
B. Soft restraints: Soft restraints are not necessary for the care of a newborn with a myelomeningocele unless there is a specific concern for the infant’s safety. Restraints should not be routinely used unless deemed absolutely necessary.
C. Sterile saline: Sterile saline is essential for cleaning and maintaining the integrity of the myelomeningocele sac. The sac should be kept moist with sterile saline to prevent it from drying out or becoming infected. This is a critical to have at the bedside for proper care.
D. Rectal thermometer: A rectal thermometer should be avoided in infants with a myelomeningocele, especially if the sac involves the lower spinal cord, as it can potentially cause injury to the delicate tissue or result in a risk of infection.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices:
- Consult the child life specialist for guidance: A child life specialist can help the parent navigate the difficult conversation with their adolescent, providing strategies for addressing sensitive topics like metastasis and death.
- Reinforce teaching to the parent regarding the adolescent's potential emotional responses: Educating the parent on common emotional responses helps them prepare for and better support their adolescent through this challenging time.
Rationale for Incorrect Choices:
- Encourage the parent to hide their emotions from their adolescent: Hiding emotions can create barriers to trust and communication, which can make the adolescent feel isolated or confused.
- Instruct the parent to withhold the test results from their adolescent: Withholding important information can prevent the adolescent from understanding their condition and making informed decisions about their care.
- Discourage the parent from discussing the possibility of death with their adolescent: Avoiding discussions about death can prevent the adolescent from processing their emotions and understanding the reality of their situation.
- Collaborate with the RN to initiate a referral for admission to hospice care: Hospice care should only be considered after emotional support and clear communication have been established, not prematurely without addressing emotional needs first.
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